Okay, if you've been following through with
the videos, you have done the hard work.
Congratulations of learning
a lot about nitroglycerin.
Now, this one is a pretty simple slide,
I promise. It's a cool drawing,
but this just tells you,
"Wow, that's impressive.
We can give nitroglycerin
lots of different ways."
Sublingual, under the tongue;
trans-lingual, in the mouth;
oral, swallowing a pill; transdermal,
a patch, or IV infusion.
So, that's a pretty complete list. We can give
nitroglycerin in all those different routes.
Now, why do we pick what we pick?
Let's break them down.
If you give it sublingual, that means
right underneath the tongue, so
you have the patient -- Okay,
the next time you're looking at a mirror,
I want you to look underneath your tongue.
There's a lot of blood vessels
So it's an amazing place to
So, it will be absorbed directly from that
oral mucosa right into the bloodstream.
You have to encourage your patients,
don't chew the pill,
don't swallow the pill.
It needs to melt right underneath
It bypasses the liver initially, so we don't
have to deal with first pass effect.
That's really cool.
That's why those nitro pills
are really, really tiny
because that dose gets -- boom,
right into the bloodstream.
The patient will feel the effect
in 1 to 3 minutes,
so sublingual routes are really fast,
whether we're giving nitroglycerin,
or another medication we
can give sublingual
are antinausea medications. That's awesome
because who wants to swallow anything
when they feel nauseated, and
you definitely want relief, quick.
So sublingual is really, really
quick. It bypasses the liver.
We're not dealing with first pass
effect. And here's the rule.
If someone has chest pain, and they
have a prescription for nitroglycerin
or it's been ordered, you give 1 tablet --
First of all, you get their
level of pain, 1 to 10.
You give 1 tablet -- underneath the tongue.
You wait 5 minutes. You assess
what their level of pain is.
You would expect that it would be lower,
but if it's not relieved, you
give another tablet.
Wait another 5 minutes, reassess,
and then give a third tablet.
Now, if after 5 minutes after
the third tablet
and that chest pain has not been relieved,
then you need to progress and
go to an emergency room.
So that's the rule; 1 tablet
every five minutes
up to 3 doses. If that doesn't
relieve the chest pain,
now we're progressing to
unstable angina, okay?
That's 1 of your signs and symptoms.
So, you want to educate your patients
that, "Hey, after 3 tabs,
if that doesn't work, you need to immediately
come in for healthcare."
Now, translingual. It's really important
that they don't get this mixed
up with an inhaler.
You don't want them to -- inhale the spray.
It's absorbed right from the oral mucosa
into the bloodstream, same thing.
It's not effective if they
try and swallow it.
It needs to be absorbed in the mouth,
just like we did with sublingual.
So, translingual sounds a little different,
but it's actually the same
concept as sublingual.
Now, if we're giving an oral medication,
that means you're swallowing it.
It's going into your GI tract.
This is more sustained
So this wouldn't be something we
would use for an acute attack.
I could use the sublingual or the
translingual for an acute attack,
but I would not use oral because
it's sustained release.
It takes a long time.
So we just use it for prophylaxis.
And when you see that term,
that's meant to, "I want to try and
minimize the number of attacks
that you have in the future."
It won't deal with an attack right now.
So, underline the word "prophylaxis."
Make sure you're very clear
on the definition.
Write that in your own words,
so we know that it's not for acute treatment,
it's for preventative, or prophylactic
Now, the drawback
to sustained release or prophylactic
is with this type of nitroglycerin,
you have an increased risk
of developing tolerance.
So we want to be really careful with
this. We don't usually use this
without really keeping an eye on is
the patient developing tolerance?
Well, how would we know that
they're developing tolerance?
Well, the doses of nitroglycerin
would no longer be effective,
or we start having more breakthrough
So, this is the dose
or this is the route that can really have
a risk for increasing tolerance.
When we talk about patches,
one of the things that we deal with with
patches is we make sure the patient
removes that patch every day,
so it minimizes the risk of tolerance.
Well, let's break these down a little more.
Nitroglycerin patches, they're real sticky,
and they put them on their chest wall.
It's important when they take the
patches off, they rotate sites.
Now, when I had to be on a blood pressure
medication that was a patch,
I was on Clonidine, my skin did
not like the adhesive at all.
So you could see where every patch
had been for the last several months,
all the way around on my body. So,
some patients may be sensitive
to the adhesive.
But when you put a patch on,
it's the body heat that will slowly
release and absorb it
through the skin and into the bloodstream.
So, remember, sublingual was superfast.
Patches are much slower to kind of
get into the bloodstream.
It takes 30-60 minutes.
Remember, sublingual could start
in as quick as 60 seconds.
So they put it on once a day and it's really
a problem for gentlemen who are hairy.
So they can't apply the patch over
hair, otherwise, it just kind of
hovers over the skin.
We need to have really tight and
close contact to skin,
so some people even have to shave a
little spot on where you can put a patch.
So I'd already talked about rotating sites
because that can be a problem if you have
a difficulty with the adhesive like I do.
And you want to be patch-free
10-12 hours is great,
but at least 8 hours and usually
we do it at night,
unless that's when you're having chest pain.
So, one question for you.
Why do we have patients take
their patches off,
usually at night, every day?
Okay, I hope you got the answer.
We have them take their patches off because
you want to reduce the risk
of developing tolerance.
Now, IV nitroglycerin has a
little bit different use.
It's a really short duration,
so it has to be given
continuously if you're going
to give it the IV route.
You can't just walk in and give
them a shot of nitroglycerin.
You hang an IV bottle of nitroglycerin
and they have a continuous infusion.
So, it's rarely used to treat chest pain.
It's used with heart failure
or with heart attack,
or maybe to try to deal with your
blood pressure during surgery,
but this is not something that you're
going to regularly see used.
It's rarely used to treat
chest pain unless we've got it becoming
very, very complicated.
Now, remember, that means like the
patient has congestive heart failure.
They definitely have an MI, an infarct.
They're having a hard time controlling their
blood pressure during a surgery,
or they just have such uncontrolled
chronic angina on a big attack,
they might go to that. But
that's a sign to you.
If we have to hang IV nitroglycerin to
control a patient's chest pain,
this is really a significant event.
You have to watch them on a monitor if
you have them on IV nitroglycerin.
You want to watch their heart rate and you
want to watch their blood pressure
very, very closely.
Remember, this causes that venous dilation,
so it can really drop their blood pressure.
And if you want to talk about a headache,
IV routes can really give your
patient a headache.
It also needs some special IV tubing.
That's just a little fun fact,
a little trivia for you about
So, this is not a great sign when you
see this for treating chest pain.
If we have to use an IV drip,
things have not gone well.
And I've listed the other reasons that
you'd use IV nitroglycerin,
during surgery or really complex cases.
Okay, this slide is our gift to you.
This is a slide that summarizes lots
of things that we talked about.
So, look at this. For acute angina treatment,
I'd consider sublingual or translingual.
For long-term prophylaxis,
patches, ointments, which you really
don't see very much anymore,
or sustained release oral capsules.
These are not appropriate for acute angina,
but they helped me with long term
to prevent angina attacks.
And then also, you'll see on the end, abort
an ongoing attack in anticipation
So, if I'm going to do something
that I know risked chest pain,
I can actually take
sublingual or translingual before
I go through that experience.
So, this slide is really important for you.
Make sure you highlight it in your notes.
And when you walk through this slide, the
most effective way to do it is say --
All right, put your finger on 1
of the routes and say,
"What do I remember? Would we use this for
acute or would we use this for long term?"
So that's step 1.
Just work your way through with
covering up the answers.
"Would I use this for acute or would
I use this for long term?"
and make sure you're solid on that concept.
Next, find a blank spot in your note and
write "acute" and "long term,"
and see if you can come up
with the different routes
without looking at your notes.
Okay, I hope you're following
our tips and strategies,
not because we want to boss you
around and tell you what to do,
but because we know these are
that will help you encode that
information in your brain.
And you've probably heard me say
that before in other videos,
but I am passionate about this.
I want to help students use the small
amount of time that they have available
with all your life's responsibilities to
really understand these concepts.
If you follow along with us and try these
things, they might feel uncomfortable,
but that's awesome. Because remember,
the struggle is where the learning happens.
Okay, there's the red box.
So the adverse effects under nitroglycerin,
we've got about 3 main ones for
you to think of. First one,
Now, it should get better
after the patient is on nitroglycerin
over a period of time.
You can use Tylenol or some other mild
analgesic to deal with the headache.
orthostatic hypotension, that
means because the --
it's a venous dilator, the blood
will pool in your veins
and your blood pressure will fall,
and so will you.
So remind your patients, if they're
going from lying to sitting,
sitting to standing, do it slowly,
and kind of wait for your body to acclimate
when you first go to sitting. Sit
there for a little bit,
and when you stand up,
stand there for a little bit.
Make sure you have something to brace
yourself in case you get dizzy.
Because I know when I was on certain
blood pressure medications,
if I hopped up too quickly,
wow, the whole world spinned around.
It felt like I was on a carnival ride.
So adverse effects: headache,
hypotension, and you're gonna
have a heart rate problem.
So there are 3 H's for
you with nitroglycerin:
headache, hypertension, and heart rate.
So draw yourself 3 capital letters right
there in the side, so you can remember.
You might even put them right on the bottle,
that'd be a cool place to put them.
You have reflex tachycardia. Your heart
rate gets really fast
because your body is compensating for
that drop in blood pressure.